Sutcliffe Kathleen M. - Still not safe: patient safety and the middle -managing of American medicine

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PART I: The Rise of Patient Safety

PART II: The Reign of Patient Safety

PART III: The Waning of Patient Safety

Medicines simplified idea of science is not the creative social enterprise that sociologists and philosophers of science have described over the last 30 [now, 40] years, but rather the realist vision of physical certainty taught in grade school and presented in the media.

Kathryn Montgomery

The American moral and social philosopher Eric Hoffer reportedly said that every great cause begins as a movement, becomes a business, and eventually degenerates into a racket. The reform movement to make healthcare safer is clearly a great cause, but patient safety efforts are increasingly following Hoffers path.

In 1999, the Institute of Medicines To Err Is Human reportfor external intervention) because, after all, health professionals (especially managers) have the situation well in hand.

The result of this co-option has allowed assumptions about how accidents happen and how best to prevent, manage, or mitigate them to go unexamined and uninformed by current thinking in safety science, in part because examining those assumptions would challenge the authority of a managerial class of doctors and other health professionals whose power and control of healthcare processes has been steadily increasing. It has limited the depth of exploration of safety topics. Worse, it has resulted in the progressive loss of input and expertise from the very safety sciences (psychology, sociology, organizational behavior, human factors engineering, and others) that energized the founding of the patient safety movement with hopes for new approaches to hazards.

This book explores the reasons for this emergence, breakthrough, and decline. It results from a Robert Wood Johnson Foundationfunded study of the evolution of the modern patient safety movement from its beginnings to its present form and constructively critiques an important social movement which has seemingly lost its way. It is not a general text on patient safety; there are many such texts available understanding this course of development and the forces that led to it will be important for safety efforts in healthcare to break out of their current doldrums.

Montgomery, Kathryn. 2005. How Doctors Think: Clinical Judgment and the Practice of Medicine. Oxford: Oxford University Press .

Kohn, Linda T., Janet M. Corrigan, and Molla S. Donaldson. 2000. To Err Is HumanBuilding a Safer Health System. Washington, DC: National Academy Press .

Lamont, Tara, and Justin Waring. 2015. Safety Lessons: Shifting Paradigms and New Directions for Patient Safety Research. Journal of Health Services Research & Policy 20 (1 suppl):18. doi: 10.1177/1355819614558340 .

Dekker, Sidney W. A. 2011. Patient Safety: A Human Factors Approach. Boca Raton, FL: CRC Press .

Vincent, Charles. 2010. Patient Safety. 2nd ed. Oxford: Wiley Blackwell .

Hilgartner, Stephen, and Charles L. Bosk. 1988. The Rise and Fall of Social Problems: A Public Arenas Model. American Journal of Sociology 94 (1):5378 .

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We first and foremost thank the Robert Wood Johnson Foundation and their generous support of our research through its Investigators Award Program. We also thank our universities and our colleagues at the University of Florida College Of Medicine - Jacksonville and Johns Hopkins University Carey Business School, School of Medicine and Armstrong Institute for Patient Safety and Quality. We are especially grateful to a host of valued colleagues who generously shared with us their time and insights in the development and subsequent course of patient safety. These include: James Reason, Charles Vincent, Jeffrey Cooper, David Gaba, Richard Cook, Lori Zipperer, John Eichorn, Jan Davies, David Musson, Rhona Flin, Troyen Brennan, Erik Hollnagel, Sidney Dekker, James Nyce, Johan Bergstrm, Martie Hatlie, Gary Klein, Stephen Hargarten, Kerm Henriksen, Lucian Leape, Donald Berwick, Helen Haskell, Justin Waring, Sonja Jerak-Zuiderent, and Teun Zuiderent-Jerak, and twenty anonymous healthcare patient safety officers. We also thank two students whose theses addressed the development of patient safety thinking: Eric Van Rite and Charlotte Soldan, and further thank Lindsey Clark of Georgetowns Medical Innovation Institute for her assistance in interviewing.

We particularly thank people whose work on safety we admire; we have been strongly influenced by the thinking of Richard Cook, David Woods, Erik Hollnagel, Charles Vincent, Karl Weick, Justin Waring, Sidney Dekker, Charles Bosk, Eric Van Rite, Tim Vogus, Lori Paine, Peter Pronovost, Daved van Stralen, Marlys Christianson, Jeffrey Braithwaite, and James Scott.